PACIO Advance Directive Interoperability Implementation Guide
1.0.0 - STU 1
PACIO Advance Directive Interoperability Implementation Guide
1.0.0 - STU 1
This page is part of the PACIO Advance Directive Information Implementation Guide (v1.0.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
<Bundle xmlns="http://hl7.org/fhir">
<id value="Example-McBee-Bundle1"/>
<identifier>
<system value="urn:oid:2.16.840.1.113883.3.3208.101.1"/>
<value value="20130607100315-CCDA-CCD"/>
</identifier>
<type value="document"/>
<timestamp value="2019-12-06T10:11:30.001-04:00"/>
<entry>
<fullUrl
value="http://www.example.org/fhir/Composition/Example-McBee-PACPComposition1"/>
<resource>
<Composition>
<id value="Example-McBee-PACPComposition1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PACPComposition"/>
</meta>
<language value="en-US"/>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><p><b>Generated Narrative: Composition</b><a name="Example-McBee-PACPComposition1"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Composition "Example-McBee-PACPComposition1" (Language "en-US") </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-ADI-PACPComposition.html">ADI Personal Advance Care Plan Composition</a></p></div><p><b>Version Number</b>: 1</p><p><b>Data Enterer</b>: <a href="#Patient_Example-McBee-Patient1">See above (Patient/Example-McBee-Patient1)</a></p><p><b>Effective Date</b>: 2018-08-28 08:49:58-0400 --> (ongoing)</p><p><b>Informant</b>: <a href="#RelatedPerson_Example-McBee-HealthcareAgent1">See above (RelatedPerson/Example-McBee-HealthcareAgent1)</a></p><p><b>Participant</b>: <a href="#RelatedPerson_Example-McBee-HealthcareAgent1">See above (RelatedPerson/Example-McBee-HealthcareAgent1)</a></p><p><b>Performer</b>: <span>: Advance Directives, Inc.</span></p><p><b>identifier</b>: id: 20130607100315-CCDA-CCD</p><p><b>status</b>: final</p><p><b>type</b>: Patient Personal advance care plan <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a>#81334-5)</span></p><p><b>category</b>: Advance directives <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a>#42348-3)</span></p><p><b>date</b>: 2018-08-28 08:49:58-0400</p><p><b>author</b>: <a href="#Patient_Example-McBee-Patient1">See above (Patient/Example-McBee-Patient1)</a></p><p><b>title</b>: Personal Advance Care Plan Document for Roger McBee</p><p><b>custodian</b>: <a href="#Organization_Example-McBee-OrganizationCustodian1">See above (Organization/Example-McBee-OrganizationCustodian1)</a></p></div>
</text>
<extension
url="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-versionNumber-extension">
<valueInteger value="1"/>
</extension>
<extension
url="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-dataEnterer-extension">
<valueReference>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-effective-date-extension">
<valuePeriod>
<start value="2018-08-28T08:49:58.313-04:00"/>
</valuePeriod>
</extension>
<extension
url="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-informant-extension">
<valueReference>🔗
<reference value="RelatedPerson/Example-McBee-HealthcareAgent1"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-participant-extension">
<valueReference>🔗
<reference value="RelatedPerson/Example-McBee-HealthcareAgent1"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-performer-extension">
<valueReference>
<display value="Advance Directives, Inc."/>
</valueReference>
</extension>
<identifier>
<system value="urn:oid:2.16.840.1.113883.4.823.1.7124"/>
<value value="20130607100315-CCDA-CCD"/>
</identifier>
<status value="final"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="81334-5"/>
<display value="Patient Personal advance care plan"/>
</coding>
</type>
<category>
<coding>
<system value="http://loinc.org"/>
<code value="42348-3"/>
<display value="Advance directives"/>
</coding>
</category>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<date value="2018-08-28T08:49:58.313-04:00"/>
<author>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</author>
<title value="Personal Advance Care Plan Document for Roger McBee"/>
<custodian>🔗
<reference
value="Organization/Example-McBee-OrganizationCustodian1"/>
</custodian>
<section>
<extension
url="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-clause-extension">
<extension url="Clause">
<valueMarkdown
value="I am appointing the person or persons below as my healthcare agent and, if applicable, as my
alternate healthcare agent(s), and I am granting to each of them the legal authority to make
medical treatment decisions on my behalf and to consult with my physician and others. The
power to make medical treatment decisions that I am granting to my healthcare agent(s) is
expressly subject to, and limited by, the choices that I have expressed elsewhere.
If my medical treatment choices are not clear, I am authorizing and directing my healthcare
agent to make decisions in my best interests and based on what is known of my wishes."/>
</extension>
</extension>
<title
value="Appointment of a Primary Healthcare Agent and Alternate Healthcare Agents"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="81335-2"/>
<display value="Healthcare Agent"/>
</coding>
</code>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>It is very important for you to discuss your medical treatment goals and wishes with your healthcare agent, your family, and your medical care providers.</b> Keep in mind that advance medical directives are simply expressions of your medical treatment goals and preferences. There is no guarantee that your medical care providers will follow all of your wishes, but one thing is certain: <b>If your advance medical directives cannot be quickly located and retrieved in a time of need, then medical care providers, your family and friends will not be able to take your wishes into consideration when they make critical decisions regarding your treatment.</b></p><p><i>IF THIS PART OF THE uADD™ IS LEFT BLANK, I DO NOT WANT TO DESIGNATE A HEALTHCARE AGENT AT THIS TIME, AND I DO NOT WANT A DEFAULT HEALTHCARE AGENT DESIGNATED FOR ME UNDER APPLICABLE LAW. I TRUST THE DOCTORS AND NURSES TREATING ME TO MAKE MEDICAL TREATMENT DECISIONS REGARDING MY TREATMENT AND CARE.</i></p><p>I am appointing the person or persons below as my healthcare agent and, if applicable, as my alternate healthcare agent(s), and I am granting to each of them the legal authority to make medical treatment decisions on my behalf and to consult with my physician and others. The power to make medical treatment decisions that I am granting to my healthcare agent(s) is expressly subject to, and limited by, the choices that I have expressed elsewhere in my uADD. If my medical treatment choices are not clear, I am authorizing and directing my healthcare agent to make decisions in my best interests and based on what is known of my wishes.</p><p><b>Primary Healthcare Agent</b></p><p>The person I choose as my Primary Healthcare Agent is:</p><p><i>Sally Bobbins</i></p><p><i>SallyBobbins@example.com</i></p><p><i>[SELECTED to act as a healthcare agent on 3/23/2018, at 9:13 AM CST]</i></p><p><i>[As of 12/6/2019, at 1:11 AM CDT, a response is still PENDING]</i></p><p><b>First Alternate Healthcare Agent</b></p><p>If this healthcare agent is unable or unwilling to make medical treatment decisions for me, or if my spouse is designated as my primary healthcare agent and our marriage is annulled, or we are divorced or legally separated, then my next choice for a healthcare agent is:</p><p><i>S. Leonard Susskind (Friend)</i></p><p><i>ssuskind@example.com</i></p><p><i>[SELECTED to act as a healthcare agent on 3/23/2018, at 9:13 AM CST]</i></p><p><i>[ACCEPTED to act as a healthcare agent on 3/23/2018, at 9:14 AM CST]</i></p><p><b>My Healthcare Agent’s General Authority</b></p><p>Subject to my medical treatment choices expressed elsewhere in this uADD™ and applicable law that requires otherwise, <i>I grant to my healthcare agent the power to make all choices and medical treatment decisions for me.</i></p><p>Here are some specific instructions that expand or limit the powers I have just granted to my healthcare agent(s):</p><ul><li>If my healthcare agent's decisions conflict with my instructions, <i>I want my healthcare agent's decisions to take priority.</i></li><li>If I cannot express my own wishes for medical treatment, <i>I would like the doctors treating me, as well as my healthcare agent if I have chosen one, to make decisions based as much as possible and appropriate on my instructions below.</i></li><li>If at some point in the future I am declared incompetent, <i>I DO NOT want to be allowed to override these preferences. I want my doctors to follow the preferences I express in this document.</i></li></ul><p>Unless I have stated otherwise somewhere else in this uADD™, I understand that my healthcare agent may reconsider my medical treatment choices expressed above in light of my other instructions contained elsewhere in this uADD™ or new medical information.</p></div>
</text>
<entry>🔗
<reference value="RelatedPerson/Example-McBee-HealthcareAgent1"/>
</entry>
<entry>🔗
<reference value="RelatedPerson/Example-McBee-HealthcareAgent2"/>
</entry>
<entry>🔗
<reference value="Consent/Example-McBee-HealthcareAgentConsent"/>
</entry>
</section>
<section>
<title
value="Patient Goals, Preferences, and Priorities for Care Experience"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="81338-6"/>
<display
value="Patient Goals, Preferences, and Priorities for Care Experience"/>
</coding>
</code>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><i>MyDirectives® offers people a list of optional questions that can be answered by typing text in a text box or by uploading a video or audio file for each question. Only those questions answered by Roger Rienman McBee appear here. For a complete list of questions in My Thoughts, please visit www.MyDirectives.com.</i></p><p><b>In case I’m being cared for by a person(s) who doesn't know me very well, I’d like my following thoughts to be known.</b></p><p><b>My likes / joys:</b> Here are some examples of the things that I would like to have near me, music that I’d like to hear, and other details of my care that would help to keep me happy and relaxed:</p><p><i>Like Bach, especially the cantatas. St. Martin in the Fields</i></p><p></p><p><b>How to care for me:</b> If I become incapacitated and cannot express myself, here is what I would like to tell my healthcare agent, family and friends about how I would like for them to care for me:</p><p><i>I don’t like being treated like an object. I would like to be greeted like a person before working on me.</i></p><p></p><p><b>Please attempt to notify someone from my religion at the following phone number:</b> (If I have included one)</p><p><i>Not Religious</i></p><p></p><p><b>My unfinished business:</b> If it appears that I am approaching the end of my life, and I cannot communicate with persons around me, I would want my doctors and nurses, my family, and my friends to know about some unfinished business that I need to address:</p><p><i>I am awaiting a message from the Noble Committee. Please keep me alive if I look promising this year.</i></p></div>
</text>
<entry>🔗
<reference
value="Observation/Example-McBee-CareExperiencePreference1"/>
</entry>
<entry>🔗
<reference
value="Observation/Example-McBee-CareExperiencePreference2"/>
</entry>
<entry>🔗
<reference
value="Observation/Example-McBee-CareExperiencePreference3"/>
</entry>
<entry>🔗
<reference
value="Observation/Example-McBee-CareExperiencePreference4"/>
</entry>
<entry>🔗
<reference
value="List/Example-McBee-PersonalPrioritiesOrganizer1"/>
</entry>
</section>
<section>
<title
value="Goals, Priorities, and Preferences under certain health condition"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="81336-0"/>
<display
value="Patient Goals, preferences, and priorities under certain health conditions"/>
</coding>
</code>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>My Advance Care Goals</b></p><p>If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me:</p><ol><li><i>Being at peace with my God</i></li><li><i>Dying at home</i></li><li><i>Being able to feed, bathe, and take care of myself</i></li><li><i>Being free from pain</i></li><li><i>Resolving conflicts</i></li><li><i>Being with my family</i></li><li><i>Not being a financial burden to my family</i></li></ol><p>If I am having significant pain or suffering, <i>I would like my doctors to consult a Supportive and Palliative Care Team to help treat my physical, emotional and spiritual discomfort, and to support my family.</i></p><p><b>My Preferences in Specific Circumstances</b></p><p>In addition to the general advance care goals provided above, below are specific treatment preferences with respect to certain specific circumstances or situations.</p><p></p><p>If my health ever deteriorates due to a terminal illness, and my doctors believe I will not be able to interact meaningfully with my family, friends, or surroundings, <i>I prefer that they stop all life-sustaining treatments and let me die as gently as possible. I realize that I will not receive life-sustaining treatments including but not limited to breathing machines, blood transfusions, dialysis, heart machines, and IV drugs to keep my heart working. I also realize that medical personnel will not attempt cardiopulmonary resuscitation (CPR), and they will allow me to die naturally.</i></p><p></p><p>If my response above indicates that I do not want life-sustaining treatments,</p><p>I expressly authorize my attending physician to withhold or withdraw artificial nutrition and hydration and instruct my healthcare agent (or, if I have not designated a healthcare agent, my default surrogate), my family and the doctors and nurses who are taking care of me to respect this request.</p><p></p><p>If I have a severe, irreversible brain injury or illness and can’t dress, feed, or bathe myself, or communicate my medical wishes, but doctors can keep me alive in this condition for a long period of time, <i>I would like for them to keep trying life-sustaining treatments for 2 months.</i></p><p></p><p>Although I understand that, depending on the situation and circumstances, medical personnel may not be able to follow my wishes, here are my general thoughts on cardiopulmonary resuscitation (CPR):</p><p><i>I do not want CPR attempted.</i></p><p><i>I want my healthcare agent to make the decision, but if my chances are slim to none that I'll leave the hospital, even if they resuscitate me, then I absolutely do not want CPR.</i></p><p></p><p><b>Other Instructions</b></p><p>If it were possible to choose, here is where I would like to spend my final days:</p><p><i>At home.I would like to receive hospice care at home if possible.</i></p></div>
</text>
<entry>🔗
<reference value="CarePlan/Example-McBee-PreferenceCarePlan1"/>
</entry>
</section>
<section>
<title value="Goals, Preferences and Priorities upon Death"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="81337-8"/>
<display
value="Patient Goals, Preferences, and Priorities Upon Death"/>
</coding>
</code>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Consent to Donate</b></p><p><i>I don’t want to donate my organs.</i></p><p></p><p><b>Autopsy</b></p><p><i>I want an autopsy if my doctor thinks it will help others.</i></p><p><b>Here are my thoughts on funeral or burial plans:</b></p><p>If I were to pass away: <i>I have a plot. My wife has the details, also my secretary, Ms. Williams, will know.</i></p></div>
</text>
<entry>🔗
<reference
value="Observation/Example-McBee-OrganDonationObservation1"/>
</entry>
<entry>🔗
<reference value="Observation/Example-McBee-AutopsyObservation1"/>
</entry>
<entry>🔗
<reference
value="Observation/Example-McBee-PersonalInterventionPreference8"/>
</entry>
</section>
<section>
<title value="Witnesses and Notary"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="81339-4"/>
<display value="Witness and Notary Document"/>
</coding>
</code>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>I am emotionally and mentally competent to make this uADD. I understand the purpose and effect of this uADD, I agree with everything that is written in this uADD, and I have made this uADD knowingly, willingly and after careful deliberation.</b></p><table><tbody><tr><td><b>Signature:</b></td><td>Roger R. McBee</td></tr><tr><td><b>Date:</b></td><td>8/28/2018</td></tr></tbody></table><p></p><p><b>Statement of Witnesses</b></p><p></p><p>I declare that the person who signed this uADD, or who asked another to sign this uADD on his/her behalf, is the individual identified in the document, and he/she did so in my presence or otherwise provided satisfactory proof to me of his/her identity. I believe him/her to be of sound mind and at least 18 years of age. I personally witnessed him/her sign this document or ask the person indicated to do so, or I received proof of his/her identity that I believe is adequate, and I believe that he/she did so voluntarily. By signing this document as a witness, I certify that I am:</p><ol><li>At least 18 years of age.</li><li>Not related to the person signing this document by blood, marriage or adoption.</li><li>Not a healthcare agent appointed by the person signing this document.</li><li>Not directly financially responsible for that person’s healthcare.</li><li>Not a healthcare provider directly serving the person at this time.</li><li>Not an employee (other than a social worker or chaplain), officer, director, or partner of a healthcare provider (or any parent organization of such healthcare provider) directly serving the person at this time.</li><li>Not aware that I am entitled to or have a claim against the person’s estate.</li></ol><p></p><table><tbody><tr><td><b>Witness Number:</b></td><td></td></tr><tr><td><b>Signature:</b></td><td></td></tr><tr><td>Date:</td><td></td></tr></tbody></table></div>
</text>
</section>
</Composition>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Patient/Example-McBee-Patient1"/>
<resource>
<Patient>
<id value="Example-McBee-Patient1"/>
<meta>
<lastUpdated value="2021-04-07T19:55:22+00:00"/>
<profile
value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient"/>
</meta>
<language value="en-US"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"><p><b>Generated Narrative: Patient</b><a name="Example-McBee-Patient1"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Patient "Example-McBee-Patient1" Updated "2021-04-07 19:55:22+0000" (Language "en-US") </p><p style="margin-bottom: 0px">Profile: <a href="http://hl7.org/fhir/us/core/STU4/StructureDefinition-us-core-patient.html">US Core Patient Profile</a></p></div><p><b>identifier</b>: Social Beneficiary Identifier: <a href="http://terminology.hl7.org/5.4.0/NamingSystem-ssn.html">#</a>555-12-1246, Driver's License Number: <a href="http://terminology.hl7.org/5.4.0/NamingSystem-FloridaDLN.html">#</a>33487</p><p><b>active</b>: true</p><p><b>name</b>: McBee, Roger Rienman</p><p><b>telecom</b>: <a href="tel:+1(469)238-2858">+1(469)238-2858</a>, <a href="tel:+1(214)497-9529">+1(214)497-9529</a>, <a href="mailto:rogerb@example.com">rogerb@example.com</a></p><p><b>gender</b>: male</p><p><b>birthDate</b>: 1945-04-01</p><p><b>address</b>: 12345 Main Street Orlando FL 75219 US </p><p><b>maritalStatus</b>: NoInformation <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.4.0/CodeSystem-v3-NullFlavor.html">NullFlavor</a>#NI)</span></p></div>
</text>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="SB"/>
<display value="Social Beneficiary Identifier"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-ssn"/>
<value value="555-12-1246"/>
</identifier>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="DL"/>
<display value="Driver's License Number"/>
</coding>
</type>
<system value="urn:oid:2.16.840.1.113883.4.3.12"/>
<value value="33487"/>
</identifier>
<active value="true"/>
<name>
<text value="McBee, Roger Rienman"/>
<family value="McBee"/>
<given value="Roger"/>
<given value="Rienman"/>
</name>
<telecom>
<system value="phone"/>
<value value="+1(469)238-2858"/>
<use value="home"/>
<rank value="1"/>
</telecom>
<telecom>
<system value="phone"/>
<value value="+1(214)497-9529"/>
<use value="mobile"/>
<rank value="2"/>
</telecom>
<telecom>
<system value="email"/>
<value value="rogerb@example.com"/>
<use value="mobile"/>
<rank value="3"/>
</telecom>
<gender value="male"/>
<birthDate value="1945-04-01"/>
<address>
<type value="physical"/>
<line value="12345 Main Street"/>
<city value="Orlando"/>
<state value="FL"/>
<postalCode value="75219"/>
<country value="US"/>
</address>
<maritalStatus>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/>
<code value="NI"/>
</coding>
</maritalStatus>
</Patient>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/RelatedPerson/Example-McBee-HealthcareAgent1"/>
<resource>
<RelatedPerson>
<id value="Example-McBee-HealthcareAgent1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-Participant"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Primary Healthcare Agent</b></p><p>The person I choose as my Primary Healthcare Agent is:</p><p><i>Sally Bobbins</i></p><p><i>SallyBobbins@example.com</i></p><p><i>[SELECTED to act as a healthcare agent on 3/23/2018, at 9:13 AM CST]</i></p><p><i>[As of 12/6/2019, at 1:11 AM CDT, a response is still PENDING]</i></p></div>
</text>
<patient>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</patient>
<name>
<text value="Sally, Bobbins"/>
<family value="Bobbins"/>
<given value="Sally"/>
</name>
<telecom>
<system value="email"/>
<value value="SallyBobbins@example.com"/>
<use value="home"/>
</telecom>
</RelatedPerson>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/RelatedPerson/Example-McBee-HealthcareAgent2"/>
<resource>
<RelatedPerson>
<id value="Example-McBee-HealthcareAgent2"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-Participant"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>First Alternate Healthcare Agent</b></p><p>If this healthcare agent is unable or unwilling to make medical treatment decisions for me, or if my spouse is designated as my primary healthcare agent and our marriage is annulled, or we are divorced or legally separated, then my next choice for a healthcare agent is:</p><p><i>S. Leonard Susskind (Friend)</i></p><p><i>ssuskind@example.com</i></p><p><i>[SELECTED to act as a healthcare agent on 3/23/2018, at 9:13 AM CST]</i></p><p><i>[ACCEPTED to act as a healthcare agent on 3/23/2018, at 9:14 AM CST]</i></p></div>
</text>
<patient>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</patient>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-RoleCode"/>
<code value="FRND"/>
<display value="unrelated friend"/>
</coding>
</relationship>
<name>
<text value="Susskind, S. Leonard"/>
<family value="S. Leonard"/>
<given value="Susskind"/>
</name>
<telecom>
<system value="email"/>
<value value="ssuskind@example.com"/>
<use value="home"/>
</telecom>
</RelatedPerson>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Consent/Example-McBee-HealthcareAgentConsent"/>
<resource>
<Consent>
<id value="Example-McBee-HealthcareAgentConsent"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-ParticipantConsent"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>status</b>: active</p><p><b>scope</b>: <span title="Codes: {http://loinc.org 75786-4}">Powers granted to healthcare agent [Reported]</span></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/consentcategorycodes acd}">Advance Directive</span></p><p><b>patient</b>: <a href="Patient-Example-McBee-Patient1.html">Social Beneficiary Identifier: 555-12-1246, Roger Rienman McBee; Phone: +1(469)238-2858, Phone: +1(214)497-9529, rogerb@example.com; gender: male; birthDate: 1945-04-01</a></p><p><b>dateTime</b>: 2020-08-03</p><h3>Policies</h3><table class="grid"><tr><td>-</td><td><b>Authority</b></td><td><b>Uri</b></td></tr><tr><td>*</td><td><a href="https://www.michigan.gov/">https://www.michigan.gov/</a></td><td><a href="http://www.legislature.mi.gov/(S(tpnclc1ofteerx2x2dppcmdz))/mileg.aspx?page=GetObject&objectname=mcl-386-1998-V-5">http://www.legislature.mi.gov/(S(tpnclc1ofteerx2x2dppcmdz))/mileg.aspx?page=GetObject&objectname=mcl-386-1998-V-5</a></td></tr></table><blockquote><p><b>provision</b></p><p><b>type</b>: permit</p><blockquote><p><b>actor</b></p><p><b>role</b>: <span title="Codes: {http://loinc.org 75783-1}">Primary healthcare agent [Reported]</span></p><p><b>reference</b>: <a href="RelatedPerson-Example-McBee-HealthcareAgent1.html">Bobbins Sally ; SallyBobbins@example.com</a></p></blockquote><blockquote><p><b>actor</b></p><p><b>role</b>: <span title="Codes: {http://loinc.org 75784-9}">First alternate healthcare agent [Reported]</span></p><p><b>reference</b>: <a href="RelatedPerson-Example-McBee-HealthcareAgent2.html"><span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-RoleCode FRND}">unrelated friend</span>; Susskind S. Leonard ; ssuskind@example.com</a></p></blockquote><p><b>action</b>: <span title="Codes: {http://loinc.org 75787-2}">Advance directive - request for intubation</span>, <span title="Codes: {http://loinc.org 75788-0}">Advance directive - request for tube feeding</span>, <span title="Codes: {http://loinc.org 75789-8}">Advance directive - request for life support</span></p><p><b>purpose</b>: <span title="{http://terminology.hl7.org/CodeSystem/v3-ActReason PWATRNY}">power of attorney</span></p></blockquote></div>
</text>
<status value="active"/>
<scope>
<coding>
<system value="http://loinc.org"/>
<code value="75786-4"/>
<display value="Powers granted to healthcare agent [Reported]"/>
</coding>
</scope>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/consentcategorycodes"/>
<code value="acd"/>
<display value="Advance Directive"/>
</coding>
</category>
<patient>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</patient>
<dateTime value="2020-08-03"/>
<policy>
<authority value="https://www.michigan.gov/"/>
<uri
value="http://www.legislature.mi.gov/(S(tpnclc1ofteerx2x2dppcmdz))/mileg.aspx?page=GetObject&objectname=mcl-386-1998-V-5"/>
</policy>
<provision>
<type value="permit"/>
<actor>
<role>
<coding>
<system value="http://loinc.org"/>
<code value="75783-1"/>
<display value="Primary healthcare agent [Reported]"/>
</coding>
</role>
<reference>🔗
<reference
value="RelatedPerson/Example-McBee-HealthcareAgent1"/>
</reference>
</actor>
<actor>
<role>
<coding>
<system value="http://loinc.org"/>
<code value="75784-9"/>
<display value="First alternate healthcare agent [Reported]"/>
</coding>
</role>
<reference>🔗
<reference
value="RelatedPerson/Example-McBee-HealthcareAgent2"/>
</reference>
</actor>
<action>
<coding>
<system
value="http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS"/>
<code value="intubation"/>
<display value="Intubation"/>
</coding>
</action>
<action>
<coding>
<system
value="http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS"/>
<code value="tube-feeding"/>
<display value="Tube feeding"/>
</coding>
</action>
<action>
<coding>
<system
value="http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS"/>
<code value="life-support"/>
<display value="Life support"/>
</coding>
</action>
<purpose>
<system
value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/>
<code value="PWATRNY"/>
</purpose>
</provision>
</Consent>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/CarePlan/Example-McBee-PreferenceCarePlan1"/>
<resource>
<CarePlan>
<id value="Example-McBee-PreferenceCarePlan1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PreferenceCarePlan"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: CarePlan</b><a name="Example-McBee-PreferenceCarePlan1"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource CarePlan "Example-McBee-PreferenceCarePlan1" </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-ADI-PreferenceCarePlan.html">ADI Preference Care Plan</a></p></div><p><b>status</b>: active</p><p><b>intent</b>: proposal</p><p><b>category</b>: Advance care plan <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a>#736366004)</span></p><p><b>title</b>: Care Plan for Unconscious, vegetative state, coma for McBee</p><p><b>subject</b>: <a href="#Patient_Example-McBee-Patient1">See above (Patient/Example-McBee-Patient1)</a></p><p><b>addresses</b>: </p><ul><li><span>: Unconscious, in a coma, or in a persistent vegetative state with little or no chance of recovery</span></li><li><span>: Persistent vegetative state (SNOMED CT 24473007)</span></li><li><span>: Irreversible coma (SNOMED CT 73453007)</span></li></ul><p><b>supportingInfo</b>: </p><ul><li><a href="#Observation_Example-McBee-PersonalInterventionPreference1">See above (Observation/Example-McBee-PersonalInterventionPreference1)</a></li><li><a href="#Observation_Example-McBee-PersonalInterventionPreference2">See above (Observation/Example-McBee-PersonalInterventionPreference2)</a></li><li><a href="#Observation_Example-McBee-PersonalInterventionPreference3">See above (Observation/Example-McBee-PersonalInterventionPreference3)</a></li><li><a href="#Observation_Example-McBee-PersonalInterventionPreference4">See above (Observation/Example-McBee-PersonalInterventionPreference4)</a></li><li><a href="#Observation_Example-McBee-PersonalInterventionPreference5">See above (Observation/Example-McBee-PersonalInterventionPreference5)</a></li><li><a href="#Observation_Example-McBee-PersonalInterventionPreference6">See above (Observation/Example-McBee-PersonalInterventionPreference6)</a></li><li><a href="#Observation_Example-McBee-PersonalInterventionPreference7">See above (Observation/Example-McBee-PersonalInterventionPreference7)</a></li></ul></div>
</text>
<status value="active"/>
<intent value="proposal"/>
<category>
<coding>
<system value="http://snomed.info/sct"/>
<code value="736366004"/>
<display value="Advance care plan"/>
</coding>
</category>
<title
value="Care Plan for Unconscious, vegetative state, coma for McBee"/>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<addresses>
<display
value="Unconscious, in a coma, or in a persistent vegetative state with little or no chance of recovery"/>
</addresses>
<addresses>
<display value="Persistent vegetative state (SNOMED CT 24473007)"/>
</addresses>
<addresses>
<display value="Irreversible coma (SNOMED CT 73453007)"/>
</addresses>
<supportingInfo>🔗
<reference
value="Observation/Example-McBee-PersonalInterventionPreference1"/>
</supportingInfo>
<supportingInfo>🔗
<reference
value="Observation/Example-McBee-PersonalInterventionPreference2"/>
</supportingInfo>
<supportingInfo>🔗
<reference
value="Observation/Example-McBee-PersonalInterventionPreference3"/>
</supportingInfo>
<supportingInfo>🔗
<reference
value="Observation/Example-McBee-PersonalInterventionPreference4"/>
</supportingInfo>
<supportingInfo>🔗
<reference
value="Observation/Example-McBee-PersonalInterventionPreference5"/>
</supportingInfo>
<supportingInfo>🔗
<reference
value="Observation/Example-McBee-PersonalInterventionPreference6"/>
</supportingInfo>
<supportingInfo>🔗
<reference
value="Observation/Example-McBee-PersonalInterventionPreference7"/>
</supportingInfo>
</CarePlan>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Observation/Example-McBee-CareExperiencePreference1"/>
<resource>
<Observation>
<id value="Example-McBee-CareExperiencePreference1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-CareExperiencePreference"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>My likes / joys:</b> Here are some examples of the things that I would like to have near me, music that I’d like to hear, and other details of my care that would help to keep me happy and relaxed:</p><p><i>Like Bach, especially the cantatas. St. Martin in the Fields</i></p></div>
</text>
<status value="final"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS"/>
<code value="care-experience-preference"/>
<display value="Care experience preference"/>
</coding>
</category>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="81360-0"/>
<display value="My likes and joys [Reported]"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<effectiveDateTime value="2016-05-18T22:33:22Z"/>
<performer>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</performer>
<valueString
value="Here are some examples of the things that I would like to have near me, music that I’d like to hear, and other details of my care that would help to keep me happy and relaxed: Like Bach, especially the cantatas. St. Martin in the Fields"/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Observation/Example-McBee-CareExperiencePreference2"/>
<resource>
<Observation>
<id value="Example-McBee-CareExperiencePreference2"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-CareExperiencePreference"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>How to care for me:</b> If I become incapacitated and cannot express myself, here is what I would like to tell my healthcare agent, family and friends about how I would like for them to care for me:</p><p><i>I don’t like being treated like an object. I would like to be greeted like a person before working on me.</i></p></div>
</text>
<status value="final"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS"/>
<code value="care-experience-preference"/>
<display value="Care experience preference"/>
</coding>
</category>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="81380-8"/>
<display
value="Goals, preferences, and priorities for care experience [Reported]"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<effectiveDateTime value="2016-05-18T22:33:22Z"/>
<performer>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</performer>
<valueString
value="How to care for me: If I become incapacitated and cannot express myself, here is what I would like to tell my healthcare agent, family and friends about how I would like for them to care for me: I don’t like being treated like an object. I would like to be greeted like a person before working on me."/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Observation/Example-McBee-CareExperiencePreference3"/>
<resource>
<Observation>
<id value="Example-McBee-CareExperiencePreference3"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-CareExperiencePreference"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p></p><p><b>Please attempt to notify someone from my religion at the following phone number:</b> (If I have included one)</p><p><i>Not Religious</i></p></div>
</text>
<extension
url="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-enclosedPrecondition-extension">
<valueCodeableConcept>
<text
value="Please attempt to notify someone from my religion at the following phone number"/>
</valueCodeableConcept>
</extension>
<status value="final"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS"/>
<code value="care-experience-preference"/>
<display value="Care experience preference"/>
</coding>
</category>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="81365-9"/>
<display
value="Religious or cultural affiliation contact to notify [Reported]"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<effectiveDateTime value="2016-05-18T22:33:22Z"/>
<performer>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</performer>
<valueString value="If I have included one - Not Religious"/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Observation/Example-McBee-CareExperiencePreference4"/>
<resource>
<Observation>
<id value="Example-McBee-CareExperiencePreference4"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-CareExperiencePreference"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>My unfinished business:</b> If it appears that I am approaching the end of my life, and I cannot communicate with persons around me, I would want my doctors and nurses, my family, and my friends to know about some unfinished business that I need to address:</p><p><i>I am awaiting a message from the Noble Committee. Please keep me alive if I look promising this year.</i></p></div>
</text>
<status value="final"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS"/>
<code value="care-experience-preference"/>
<display value="Care experience preference"/>
</coding>
</category>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="81366-7"/>
<display value="Unfinished business [Reported]"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<effectiveDateTime value="2016-05-18T22:33:22Z"/>
<performer>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</performer>
<valueString
value="If it appears that I am approaching the end of my life, and I cannot communicate with persons around me, I would want my doctors and nurses, my family, and my friends to know about some unfinished business that I need to address: I am awaiting a message from the Noble Committee. Please keep me alive if I look promising this year."/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/List/Example-McBee-PersonalPrioritiesOrganizer1"/>
<resource>
<List>
<id value="Example-McBee-PersonalPrioritiesOrganizer1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalPrioritiesOrganizer"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me:</p><ol><li><i>Being at peace with my God</i></li><li><i>Dying at home</i></li><li><i>Being able to feed, bathe, and take care of myself</i></li><li><i>Being free from pain</i></li><li><i>Resolving conflicts</i></li><li><i>Being with my family</i></li><li><i>Not being a financial burden to my family</i></li></ol></div>
</text>
<status value="current"/>
<mode value="working"/>
<title value="My Advance Care Goals"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="81340-2"/>
<display
value="Goals AndOr Preferences in Order of Priority [Reported]"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<orderedBy>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/list-order"/>
<code value="priority"/>
</coding>
</orderedBy>
<entry>
<item>🔗
<reference value="Goal/Example-McBee-PersonalGoal1"/>
</item>
</entry>
<entry>
<item>🔗
<reference value="Goal/Example-McBee-PersonalGoal2"/>
</item>
</entry>
<entry>
<item>🔗
<reference value="Goal/Example-McBee-PersonalGoal3"/>
</item>
</entry>
<entry>
<item>🔗
<reference value="Goal/Example-McBee-PersonalGoal4"/>
</item>
</entry>
<entry>
<item>🔗
<reference value="Goal/Example-McBee-PersonalGoal5"/>
</item>
</entry>
<entry>
<item>🔗
<reference value="Goal/Example-McBee-PersonalGoal6"/>
</item>
</entry>
<entry>
<item>🔗
<reference value="Goal/Example-McBee-PersonalGoal7"/>
</item>
</entry>
</List>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Observation/Example-McBee-PersonalInterventionPreference1"/>
<resource>
<Observation>
<id value="Example-McBee-PersonalInterventionPreference1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>If I am having significant pain or suffering, <i>I would like my doctors to consult a Supportive and Palliative Care Team to help treat my physical, emotional and spiritual discomfort, and to support my family.</i></p></div>
</text>
<status value="final"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS"/>
<code value="intervention-preference"/>
<display value="Intervention preference"/>
</coding>
</category>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="75776-5"/>
<display
value="Preference on consulting a supportive and palliative care team to help treat physical, emotional, and spiritual discomfort and support family [Reported]"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<effectiveDateTime value="2016-05-18T22:33:22Z"/>
<performer>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</performer>
<valueString
value="If I am having significant pain or suffering, I would like my doctors to consult a Supportive and Palliative Care Team to help treat my physical, emotional and spiritual discomfort, and to support my family."/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Observation/Example-McBee-PersonalInterventionPreference2"/>
<resource>
<Observation>
<id value="Example-McBee-PersonalInterventionPreference2"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>If my health ever deteriorates due to a terminal illness, and my doctors believe I will not be able to interact meaningfully with my family, friends, or surroundings, <i>I prefer that they stop all life-sustaining treatments and let me die as gently as possible. I realize that I will not receive life-sustaining treatments including but not limited to breathing machines, blood transfusions, dialysis, heart machines, and IV drugs to keep my heart working. I also realize that medical personnel will not attempt cardiopulmonary resuscitation (CPR), and they will allow me to die naturally.</i></p></div>
</text>
<status value="final"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS"/>
<code value="intervention-preference"/>
<display value="Intervention preference"/>
</coding>
</category>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="75777-3"/>
<display
value="Information to tell doctors if my health deteriorates due to a terminal illness and I am unable to interact meaningfully with family, friends, or surroundings [Reported]"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<effectiveDateTime value="2016-05-18T22:33:22Z"/>
<performer>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</performer>
<valueString
value="If my health ever deteriorates due to a terminal illness, and my doctors believe I will not be able to interact meaningfully with my family, friends, or surroundings, I prefer that they stop all life-sustaining treatments and let me die as gently as possible. I realize that I will not receive life-sustaining treatments including but not limited to breathing machines, blood transfusions, dialysis, heart machines, and IV drugs to keep my heart working. I also realize that medical personnel will not attempt cardiopulmonary resuscitation (CPR), and they will allow me to die naturally."/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Observation/Example-McBee-PersonalInterventionPreference3"/>
<resource>
<Observation>
<id value="Example-McBee-PersonalInterventionPreference3"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>If my response above indicates that I do not want life-sustaining treatments,</p><p>I expressly authorize my attending physician to withhold or withdraw artificial nutrition and hydration and instruct my healthcare agent (or, if I have not designated a healthcare agent, my default surrogate), my family and the doctors and nurses who are taking care of me to respect this request.</p></div>
</text>
<status value="final"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS"/>
<code value="intervention-preference"/>
<display value="Intervention preference"/>
</coding>
</category>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="77352-3"/>
<display
value="Thoughts on artificial nutrition and hydration [Reported]"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<effectiveDateTime value="2016-05-18T22:33:22Z"/>
<performer>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</performer>
<valueString
value="If my response above indicates that I do not want life-sustaining treatments, I expressly authorize my attending physician to withhold or withdraw artificial nutrition and hydration and instruct my healthcare agent (or, if I have not designated a healthcare agent, my default surrogate), my family and the doctors and nurses who are taking care of me to respect this request."/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Observation/Example-McBee-PersonalInterventionPreference4"/>
<resource>
<Observation>
<id value="Example-McBee-PersonalInterventionPreference4"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>If I have a severe, irreversible brain injury or illness and can’t dress, feed, or bathe myself, or communicate my medical wishes, but doctors can keep me alive in this condition for a long period of time, <i>I would like for them to keep trying life-sustaining treatments for 2 months.</i></p></div>
</text>
<status value="final"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS"/>
<code value="intervention-preference"/>
<display value="Intervention preference"/>
</coding>
</category>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="75778-1"/>
<display
value="Information to tell doctors if I have a severe, irreversible brain injury or illness and can't dress, feed, or bathe myself, or communicate my medical wishes, but can be kept alive [Reported]"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<effectiveDateTime value="2016-05-18T22:33:22Z"/>
<performer>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</performer>
<valueString
value="If I have a severe, irreversible brain injury or illness and can’t dress, feed, or bathe myself, or communicate my medical wishes, but doctors can keep me alive in this condition for a long period of time, I would like for them to keep trying life-sustaining treatments for 2 months."/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Observation/Example-McBee-PersonalInterventionPreference5"/>
<resource>
<Observation>
<id value="Example-McBee-PersonalInterventionPreference5"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>Although I understand that, depending on the situation and circumstances, medical personnel may not be able to follow my wishes, here are my general thoughts on cardiopulmonary resuscitation (CPR):</p><p><i>I want my healthcare agent to make the decision, but if my chances are slim to none that I'll leave the hospital, even if they resuscitate me, then I absolutely do not want CPR.</i></p></div>
</text>
<status value="final"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS"/>
<code value="intervention-preference"/>
<display value="Intervention preference"/>
</coding>
</category>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="75779-9"/>
<display
value="Thoughts on cardiopulmonary resuscitation (CPR) [Reported]"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<effectiveDateTime value="2016-05-18T22:33:22Z"/>
<performer>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</performer>
<valueString
value="Although I understand that, depending on the situation and circumstances, medical personnel may not be able to follow my wishes, here are my general thoughts on cardiopulmonary resuscitation (CPR): I do not want CPR attempted."/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Observation/Example-McBee-PersonalInterventionPreference6"/>
<resource>
<Observation>
<id value="Example-McBee-PersonalInterventionPreference6"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>Although I understand that, depending on the situation and circumstances, medical personnel may not be able to follow my wishes, here are my general thoughts on cardiopulmonary resuscitation (CPR):</p><p><i>I want my healthcare agent to make the decision, but if my chances are slim to none that I'll leave the hospital, even if they resuscitate me, then I absolutely do not want CPR.</i></p></div>
</text>
<status value="final"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS"/>
<code value="intervention-preference"/>
<display value="Intervention preference"/>
</coding>
</category>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="75779-9"/>
<display
value="Thoughts on cardiopulmonary resuscitation (CPR) [Reported]"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<effectiveDateTime value="2016-05-18T22:33:22Z"/>
<performer>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</performer>
<valueString
value="Although I understand that, depending on the situation and circumstances, medical personnel may not be able to follow my wishes, here are my general thoughts on cardiopulmonary resuscitation (CPR): I want my healthcare agent to make the decision, but if my chances are slim to none that I'll leave the hospital, even if they resuscitate me, then I absolutely do not want CPR."/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Observation/Example-McBee-PersonalInterventionPreference7"/>
<resource>
<Observation>
<id value="Example-McBee-PersonalInterventionPreference7"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p>If it were possible to choose, here is where I would like to spend my final days:</p><p><i>At home.I would like to receive hospice care at home if possible.</i></p></div>
</text>
<status value="final"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS"/>
<code value="intervention-preference"/>
<display value="Intervention preference"/>
</coding>
</category>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="75780-7"/>
<display
value="Preferred location to spend final days if possible to choose [Reported]"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<effectiveDateTime value="2016-05-18T22:33:22Z"/>
<performer>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</performer>
<valueString
value="If it were possible to choose, here is where I would like to spend my final days: At home.I would like to receive hospice care at home if possible."/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Observation/Example-McBee-PersonalInterventionPreference8"/>
<resource>
<Observation>
<id value="Example-McBee-PersonalInterventionPreference8"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalInterventionPreference"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Here are my thoughts on funeral or burial plans:</b></p><p>If I were to pass away: <i>I have a plot. My wife has the details, also my secretary, Ms. Williams, will know.</i></p></div>
</text>
<status value="final"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIPreferenceCategoryCS"/>
<code value="intervention-preference"/>
<display value="Intervention preference"/>
</coding>
</category>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="81356-8"/>
<display value="Death arrangements [Reported]"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<effectiveDateTime value="2016-05-18T22:33:22Z"/>
<performer>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</performer>
<valueString
value="Here are my thoughts on funeral or burial plans: If I were to pass away:</b> <i>I have a plot. My wife has the details, also my secretary, Ms. Williams, will know."/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Goal/Example-McBee-PersonalGoal1"/>
<resource>
<Goal>
<id value="Example-McBee-PersonalGoal1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalGoal"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me:</b></p><p><i>Being at peace with my God</i></p></div>
</text>
<lifecycleStatus value="proposed"/>
<category>
<coding>
<system value="http://loinc.org"/>
<code value="87528-6"/>
<display value="Personal health goal"/>
</coding>
</category>
<description>
<text
value="If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me: Being at peace with my God"/>
</description>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<expressedBy>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</expressedBy>
</Goal>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Goal/Example-McBee-PersonalGoal2"/>
<resource>
<Goal>
<id value="Example-McBee-PersonalGoal2"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalGoal"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me:</b></p><p><i>Dying at home</i></p></div>
</text>
<lifecycleStatus value="proposed"/>
<category>
<coding>
<system value="http://loinc.org"/>
<code value="87528-6"/>
<display value="Personal health goal"/>
</coding>
</category>
<description>
<text
value="If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me: Dying at home"/>
</description>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<expressedBy>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</expressedBy>
</Goal>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Goal/Example-McBee-PersonalGoal3"/>
<resource>
<Goal>
<id value="Example-McBee-PersonalGoal3"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalGoal"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me:</b></p><p><i>Being able to feed, bathe, and take care of myself</i></p></div>
</text>
<lifecycleStatus value="proposed"/>
<category>
<coding>
<system value="http://loinc.org"/>
<code value="87528-6"/>
<display value="Personal health goal"/>
</coding>
</category>
<description>
<text
value="If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me: Being able to feed, bathe, and take care of myself"/>
</description>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<expressedBy>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</expressedBy>
</Goal>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Goal/Example-McBee-PersonalGoal4"/>
<resource>
<Goal>
<id value="Example-McBee-PersonalGoal4"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalGoal"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me:</b></p><p><i>Being free from pain</i></p></div>
</text>
<lifecycleStatus value="proposed"/>
<category>
<coding>
<system value="http://loinc.org"/>
<code value="87528-6"/>
<display value="Personal health goal"/>
</coding>
</category>
<description>
<text
value="If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me: Being free from pain"/>
</description>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<expressedBy>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</expressedBy>
</Goal>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Goal/Example-McBee-PersonalGoal5"/>
<resource>
<Goal>
<id value="Example-McBee-PersonalGoal5"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalGoal"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me:</b></p><p><i>Resolving conflicts</i></p></div>
</text>
<lifecycleStatus value="proposed"/>
<category>
<coding>
<system value="http://loinc.org"/>
<code value="87528-6"/>
<display value="Personal health goal"/>
</coding>
</category>
<description>
<text
value="If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me: Resolving conflicts"/>
</description>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<expressedBy>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</expressedBy>
</Goal>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Goal/Example-McBee-PersonalGoal6"/>
<resource>
<Goal>
<id value="Example-McBee-PersonalGoal6"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalGoal"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me:</b></p><p><i>Being with my family</i></p></div>
</text>
<lifecycleStatus value="proposed"/>
<category>
<coding>
<system value="http://loinc.org"/>
<code value="87528-6"/>
<display value="Personal health goal"/>
</coding>
</category>
<description>
<text
value="If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me: Being with my family"/>
</description>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<expressedBy>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</expressedBy>
</Goal>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Goal/Example-McBee-PersonalGoal7"/>
<resource>
<Goal>
<id value="Example-McBee-PersonalGoal7"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalGoal"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me:</b></p><p><i>Not being a financial burden to my family</i></p></div>
</text>
<lifecycleStatus value="proposed"/>
<category>
<coding>
<system value="http://loinc.org"/>
<code value="87528-6"/>
<display value="Personal health goal"/>
</coding>
</category>
<description>
<text
value="If I am so sick or seriously injured that I cannot express my own medical treatment preferences, and if I am not expected to live without additional treatment for my illness, disease, condition or injury, then I want my medical care team to know that these are the things that are most important to me: Not being a financial burden to my family"/>
</description>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<expressedBy>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</expressedBy>
</Goal>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Observation/Example-McBee-OrganDonationObservation1"/>
<resource>
<Observation>
<id value="Example-McBee-OrganDonationObservation1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-OrganDonationObservation"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Consent to Donate</b></p><p><i>I don’t want to donate my organs.</i></p></div>
</text>
<status value="final"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="75781-5"/>
<display
value="Thoughts on organ and tissue donations [Reported]"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<effectiveDateTime value="2016-05-18T22:33:22Z"/>
<performer>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</performer>
<valueString
value="Consent to Donate: I don’t want to donate my organs."/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Observation/Example-McBee-AutopsyObservation1"/>
<resource>
<Observation>
<id value="Example-McBee-AutopsyObservation1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-AutopsyObservation"/>
</meta>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Autopsy</b></p><p><i>I want an autopsy if my doctor thinks it will help others.</i></p></div>
</text>
<status value="final"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="75782-3"/>
<display value="Thoughts regarding autopsy [Reported]"/>
</coding>
</code>
<subject>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</subject>
<effectiveDateTime value="2016-05-18T22:33:22Z"/>
<performer>🔗
<reference value="Patient/Example-McBee-Patient1"/>
</performer>
<valueString
value="Autopsy: I want an autopsy if my doctor thinks it will help others."/>
</Observation>
</resource>
</entry>
<entry>
<fullUrl
value="http://www.example.org/fhir/Organization/Example-McBee-OrganizationCustodian1"/>
<resource>
<Organization>
<id value="Example-McBee-OrganizationCustodian1"/>
<meta>
<profile
value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Organization</b><a name="Example-McBee-OrganizationCustodian1"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Organization "Example-McBee-OrganizationCustodian1" </p><p style="margin-bottom: 0px">Profile: <a href="http://hl7.org/fhir/us/core/STU4/StructureDefinition-us-core-organization.html">US Core Organization Profile</a></p></div><p><b>identifier</b>: id: <a href="http://terminology.hl7.org/5.4.0/NamingSystem-npi.html">#</a>44444</p><p><b>active</b>: true</p><p><b>name</b>: MyDirectives.com</p><p><b>telecom</b>: <a href="tel:+1(202)776-7700">+1(202)776-7700</a></p><p><b>address</b>: 740 E. Campbell Rd. Suite 825 Richardson TX 75081 US </p></div>
</text>
<identifier>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="44444"/>
</identifier>
<active value="true"/>
<name value="MyDirectives.com"/>
<telecom>
<system value="phone"/>
<value value="+1(202)776-7700"/>
<use value="work"/>
</telecom>
<address>
<type value="physical"/>
<line value="740 E. Campbell Rd. Suite 825"/>
<city value="Richardson"/>
<state value="TX"/>
<postalCode value="75081"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
</Bundle>
IG © 2021+ HL7 International / Patient Empowerment. Package hl7.fhir.us.pacio-adi#1.0.0 based on FHIR 4.0.1. Generated 2024-01-11
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